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ASPE

ISSUE BRIEF
HEALTH INSURANCE MARKETPLACE:
UNINSURED POPULATIONS ELIGIBLE TO ENROLL FOR 2016
By: Kenneth Finegold, Kelsey Avery, Bula Ghose, and Caryn Marks
October 15, 2015
A central aim of the Affordable Care Act is to increase the number of Americans with health
insurance coverage. Over the past two years, significant progress has been made towards this
goal as measured by the decline in the proportion of Americans who lack health insurance
coverage, often called the uninsured rate. Using data from the Gallup-Healthways Well-Being
Index (Gallup-Healthways WBI), ASPE recently estimated that 17.6 million uninsured people
have gained health insurance coverage as several of the Affordable Care Acts coverage
provisions took effect.1
In this brief, we use recently released data from the National Health Interview Survey (NHIS) to
examine the composition of people that remained uninsured though the first quarter of 2015 and
may be eligible to purchase insurance coverage from a Qualified Health Plan (QHP) through the
Marketplaces (QHP-eligible uninsured). It also presents data on the attitudes and experiences
of the uninsured, drawn from a number of private surveys.
In a separate ASPE report, How Many Individuals Might Have Marketplace Coverage at the
End of 2016?,2 we estimate that there are 10.5 million QHP-eligible uninsured Americans. This
estimate uses both the 2013 American Community Survey (ACS) and results from the GallupHealthways WBI through the second quarter of 2015. This number represents our best estimate
of the number of QHP-eligible uninsured going into the third Open Enrollment Period. The
estimates of the number of QHP-eligible uninsured (using the ACS and Gallup-Healthways
WBI) and the composition of that population (using the NHIS) come from distinct data sources
selected to best match the objectives of each analysis. As a result, these estimates are not fully
consistent with each other.
1

Office of the Assistant Secretary for Planning and Evaluation. Health Insurance Coverage and the Affordable Care Act.
September 2015. Available at: http://aspe.hhs.gov/health-insurance-coverage-and-affordable-care-act-aspe-issue-brief-september2015.
2
Office of the Assistant Secretary for Planning and Evaluation. How Many Individuals Might Have Marketplace Coverage at
the End of 2016? October 15, 2015. Available at: http://aspe.hhs.gov/pdf-report/how-many-individuals-might-havemarketplace-coverage-at-the-end-of-2016.

Department of Health and Human Services


Office of the Assistant Secretary for Planning and Evaluation
http://www.aspe.hhs.gov/

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Key Findings:
Likely QHP-eligible Uninsured Individuals:
Income: Nearly half (48 percent) of QHP-eligible uninsured individuals have family
incomes between 100% and 250% of the Federal Poverty Level (FPL) and may qualify
for the advance payments of the premium tax credit (APTC) and cost-sharing reductions
(CSR). About 30 percent have incomes between 250% and 400% FPL and may qualify
for APTC. The remaining 22 percent have family incomes above 400% FPL.
Gender: An estimated 57 percent of the QHP-eligible uninsured are men.
Age: Almost half of QHP-eligible uninsured individuals are between the ages of 18 and
34.
Race: Approximately one-third of the QHP-eligible uninsured are people of color: 19
percent are Hispanic, 14 percent are African American, and 2 percent are Asian
American.
Gender and Race: Nearly 35 percent of the QHP-eligible uninsured are White males,
10.6 percent are Hispanic males, and 26.6 percent are White females.
All Uninsured Individuals:
Financial Circumstances: Nearly 8 in 10 of all people without insurance have less than
$1,000 in savings and about half have less than $100 in savings.
Views about Insurance: Nearly 75 percent of all uninsured people think that having
health insurance is important.
Perceptions of Affordability: People without health insurance are primarily concerned
with the affordability of coverage.
Understanding of the Health Insurance Marketplace: Nearly three in five of all
people without health insurance do not understand or are unaware of the premium tax
credits.

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October 15, 2015

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Overview
Recent analysis of Gallup-Healthways WBI data suggests that 17.6 million previously uninsured
people have gained coverage as several of the Affordable Care Acts coverage provisions have
taken effect.3 The increases in coverage reflect individuals newly covered through the
Marketplaces, Medicaid, the Childrens Health Insurance Program (CHIP), the expansion of
dependent coverage, and other sources such as employer sponsored insurance. The next Health
Insurance Marketplace Open Enrollment Period, from November 1, 2015 to January 31, 2016,
will offer an opportunity to continue to provide coverage for more individuals and to reduce the
number of uninsured even further.4
This brief uses the most recent data from the National Health Interview Survey (NHIS) to
examine the composition of people that remained uninsured though the first quarter of 2015, and
who may be eligible to purchase insurance coverage from a Qualified Health Plan (QHP)
through the Marketplaces (QHP-eligible uninsured). The NHIS is a federal survey designed to
provide reliable estimates over time and is considered to be the gold standard for measuring the
number and characteristics of the uninsured.
We use the term QHP-eligible uninsured to refer to those who are most likely to have or shop
for coverage in the Marketplaces. For the purposes of this analysis, we consider QHP-eligible
uninsured to be any nonelderly, lawfully present individual who is uninsured and has a family
income: (a) above 138% of the Federal Poverty Level (FPL) for adults in Medicaid expansion
states or at least 100% FPL for adults in states that have not yet expanded, or (b) above 250%
FPL for children in any state. Not all uninsured individuals who are QHP-eligible are
necessarily eligible for coverage or financial assistance through the Marketplaces.5 For more
information about eligibility to purchase coverage in the Marketplaces, see
https://www.healthcare.gov/quick-guide/eligibility/.
In Section I of this brief, we analyze selected characteristics of the uninsured who may be
eligible for Marketplace coverage. Our analysis is based on NHIS data for January to March
2015.
In Section II, we present data on the attitudes and experiences of the uninsured drawn from a
number of private surveys of low and middle-income populations. These analyses typically do
not make adjustments to remove immigrants who are not lawfully present (who are not eligible
for Medicaid or Marketplace coverage) or distinguish between individuals who would be eligible
3

Gallup-Healthways WBI data are through 9/12/2015. Office of the Assistant Secretary for Planning and Evaluation. Health
Insurance Coverage and the Affordable Care Act. September 2015. Available at: http://aspe.hhs.gov/health-insurance-coverageand-affordable-care-act-aspe-issue-brief-september-2015.
4
Individuals who meet the criteria for Special Enrollment Periods, or who qualify for Medicaid or CHIP, can enroll at any time.
5
For the purposes of this brief, we have not included within our definition of QHP-eligible individuals whose family incomes
are in the coverage gap (family incomes above Medicaid eligibility and below financial assistance eligibility through the
Marketplaces) in states that have not yet expanded Medicaid, as these individuals are unlikely to purchase coverage through the
Marketplaces. We also do not include in our definition lawfully present immigrants with family incomes below 100% FPL.
Likewise, there are individuals with current health coverage who may purchase coverage through the Marketplacefor example,
individuals with unaffordable or non-minimum value coverage who could drop it and enroll in a Marketplace planwho are not
included in the QHP-eligible uninsured estimates presented here.

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for different sources of coverage (Marketplace, Medicaid/CHIP, or in the Medicaid coverage gap
in states that have not expanded). However, we believe the findings gleaned from these survey
data provide insights that may apply to the likely QHP-eligible population.

SECTION I: CHARACTERISTICS OF THE QHP-ELIGIBLE UNINSURED


Using NHIS data from the first quarter of 2015, Figure 1 below provides a demographic profile
of the remaining uninsured:

Nearly half of the uninsured (49 percent) are likely QHP-eligible.6 This group is the
primary focus of this brief.
Approximately 30 percent are potentially eligible for the Medicaid program:
o About 12 percent are adults who live in Medicaid expansion states and have
family incomes below 138% FPL.
o About 11 percent are adults who live in states that have not yet expanded
Medicaid, have family incomes below 100% FPL, and who would potentially be
eligible for Medicaid if their state expanded eligibility (also called the Medicaid
coverage gap).7
o About 7 percent are children who are potentially eligible for Medicaid or CHIP
(family incomes below 250% FPL).
About 21 percent are not eligible for these programs because they are not lawfully
present in the U.S.

Rachel Garfield, Anthony Damico, Cynthia Cox, Gary Claxton, and Larry Levitt, New Estimates of Eligibility for ACA
Coverage among the Uninsured, released by the Kaiser Family Foundation on October 13, 2015 (http://kff.org/uninsured/issuebrief/new-estimates-of-eligibility-for-aca-coverage-among-the-uninsured/), analyzes the eligibility of the uninsured for insurance
affordability programs in ways that are somewhat similar to the estimates presented in Figure 1. Their analyses are based on
Calendar Year 2014 data from the March 2015 Current Population Survey Annual Social and Economic Supplement (CPS
ASEC), which does not capture the gains in coverage in 2015, or the changes in the distribution of the uninsured because the
2015 gains have been concentrated among those eligible for Marketplace subsidies or Medicaid expansion. Because higherincome individuals tend to be uninsured for shorter periods, the CPS ASEC estimate of the full-year uninsured used for the
Kaiser Family Foundation analysis has a different income distribution than the NHIS, which captures the uninsured at the time of
interview. Both the ASPE and Kaiser Family Foundation analyses suggest that nearly half the nonelderly uninsured are eligible to
select Marketplace plans.
7
Adults who live in states that have not yet expanded and have family incomes from 100% to 138% FPL are considered for the
purposes of this brief to be likely eligible for Marketplace coverage.

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Figure 1. Nonelderly Uninsured, by Eligibility for Insurance Affordability Programs

Source: ASPE analysis of National Health Interview Survey (NHIS) Preliminary Quarterly Microdata Files for January-March
2015, adjusted using imputations of immigration status from ASPEs TRIM3 microsimulation model.

Figures 2, 3, 4, and 5 below illustrate the distribution of the QHP-eligible uninsured by various
demographic characteristics.
Of the QHP-eligible uninsured:

Income: Nearly half have incomes


between 100% and 250% FPL, making
them likely to be eligible for both APTC
and CSR in the Marketplaces (Figure 2).

Employment: More than 70 percent are


employed.

Education: Approximately half have


education beyond high school. Only 13
percent do not have either a high school
diploma or a GED.

Figure 2. Distribution of QHPEligible Uninsured by Income


9%
22%

40%
30%

100-138% FPL

139-250%FPL

250-399% FPL

>400% FPL

NOTE: Totals add up to more than 100% due to rounding

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Figure 3. Distribution of QHPEligible Uninsured by Race

Race: 61 percent are White, 19 percent


are Hispanic, and 14 percent are African
American (Figure 3).

4%

2%

Health status: Nearly two-thirds are in


excellent or very good health, compared
with 8 percent whose reported health is
fair or poor.

19%

14%

61%
Hispanic (all races)
Black (non-Hispanic)
Other (non-Hispanic)

White (non-Hispanic)
Asian (non-Hispanic)

Figures 4 and 5 also illustrate key differences between the QHP-eligible uninsured and the
general nonelderly population:

Income: QHP-eligible uninsured individuals are less likely to have family incomes above
400% FPL than the nonelderly (Figure 4).
Employment: QHP-eligible uninsured adults are more than twice as likely as all nonelderly
adults to be unemployed, as opposed to employed or not in the labor force.
Marital Status: QHP-eligible uninsured adults are less likely to be single compared to the
general nonelderly adult population.
Figure 4. Distribution by Income:
QHP-Eligible Uninsured vs. General Nonelderly Population
40%

37%
30%
20%

16%
9%

19%

22%

8%

0%
100% FPL

100-138% FPL
139-250% FPL
250-399% FPL
QHP-Eligible Uninsured
General Nonelderly Population

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>400% FPL

October 15, 2015

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Education: QHP-eligible uninsured adults are about as likely as all nonelderly adults to have
less than a high school education, but more likely to have only a high school education or
GED, and less likely to have gone beyond high school (Figure 5).
Race: The QHP-eligible uninsured population is more likely to be African American, and
less likely to be Asian American, than the general nonelderly population. The proportions of
individuals who are White or Hispanic are about the same among the QHP-eligible as in the
general population.
Metropolitan status: QHP-eligible uninsured individuals are more likely than all nonelderly
adults to be residents of nonmetropolitan or rural areas.

Figure 5. Distribution by Education:


QHP-Eligible Uninsured vs. General Nonelderly Population
63%

48%
38%
25%
13%

12%

Less than High School

High School/GED

QHP-Eligible Uninsured

Post-High School

General Nonelderly Population

Table 1 presents selected characteristics of the estimated nonelderly uninsured population who
may be eligible for Marketplace coverage and the general population of nonelderly individuals.
Selected characteristics examined include: income, age, gender, education, health status, race,
metropolitan status, employment status, marital status, and usual source of care.

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Table 1. QHP-Eligible Nonelderly Uninsured and All Nonelderly, January-March


2015, by Selected Characteristics
Variable

QHP-Eligible
Uninsured
(Percentage)

General Nonelderly
Population
(Percentage)

Family Income
<100% FPL
100-138% FPL
139-250% FPL
250-399% FPL
>400% FPL
Total

N/A
8.6
39.5
29.5
22.4
100.0

15.5
8.0
20.3
19.0
37.1
100.0

Age
0-17
18-25
26-34
35-54
55-64
Total

7.5
20.5
25.9
34.6
11.5
100.0

27.3
13.0
14.0
30.7
14.9
100.0

Gender
Male
Female
Total

56.9
43.1
100.0

49.6
50.4
100.0

Race / Ethnicity
Hispanic (all races)
White (non-Hispanic)
Black (non-Hispanic)
Asian (non-Hispanic)
Other (non-Hispanic)
Total

18.6
61.4
14.2
2.2
3.6
100.0

19.2
59.5
12.7
5.7
2.9
100.0

Education Level (ages 18-64 only)


Less than High School
High School/GED
Post-High School
Total

13.4
38.3
48.3
100.0

12.3
24.8
62.9
100.0

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Table 1. QHP-Eligible Nonelderly Uninsured and All Nonelderly, January-March


2015, by Selected Characteristics (cont.)
Variable

QHP-Eligible
Uninsured
(Percentage)

General Nonelderly
Population
(Percentage)

Health Status*
Excellent
Very Good
Good
Fair/Poor
Total

34.1
30.2
27.6
8.0
100.0

40.3
30.1
21.7
7.9
100.0

Metropolitan Status
Metropolitan
Nonmetropolitan
Total

80.8
19.2
100.0

86.5
13.5
100.0

Employment Status (ages 18-64 only)


Employed
Unemployed
Not in Labor Force
Total

72.2
10.5
17.3
100.0

72.0
5.0
23.0
100.0

Marital Status (ages 18-64 only)


Married
Not Married
Total

36.7
63.3
100.0

54.2
45.8
100.0

Has Usual Source of Care*


Yes
No
Total

51.4
48.6
100.0

86.4
13.6
100.0

* Not adjusted for immigration status


Source: ASPE analysis of National Health Interview Survey (NHIS) Preliminary Quarterly Microdata
Files for January-March 2015, adjusted using imputations of immigration status from ASPEs TRIM3
microsimulation model.

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Table 2 presents additional analysis of the relationship between race/ethnicity and gender
among the QHP-eligible uninsured. Overall, men account for 57 percent of the QHP-eligible
population. The proportion of men among QHP-eligible Hispanics and Whites is similar to
the proportion of men in the overall QHP-eligible population, but is higher (60 percent)
among African Americans and lower (44 percent) among Asian Americans. More than onethird of the QHP-eligible uninsured are non-Hispanic White males.
Table 2. QHP-Eligible Nonelderly Uninsured, January-March 2015, by Race/Ethnicity
and Gender
Category
Percentage of
Percentage of
Race/Ethnicity Group
Total
Male
Hispanic (all races)
White (non-Hispanic)
Black (non-Hispanic)
Asian (non-Hispanic)
Other (non-Hispanic)
Total

56.9
56.8
59.6
44.2
57.3
56.9

10.6
34.9
8.5
1.0
2.1
56.9

Female
Hispanic (all races)
White (non-Hispanic)
Black (non-Hispanic)
Asian (non-Hispanic)
Other (non-Hispanic)
Total

43.1
43.2
40.4
55.8
42.7
43.1

8.0
26.6
5.7
1.2
1.5
43.1

Source: ASPE analysis of National Health Interview Survey (NHIS) Preliminary Quarterly Microdata
Files for January-March 2015, adjusted using imputations of immigration status from ASPEs TRIM3
microsimulation model.

SECTION II: ATTITUDES AND EXPERIENCES OF THE UNINSURED


Surveys of uninsured people fielded by the Robert Wood Johnson Foundation, the Kaiser Family
Foundation, the Commonwealth Fund, McKinsey & Company, and the Urban Institute all
provide valuable information about the attitudes and experiences of the remaining uninsured.
New content areas that are not measured by federal surveys but are included in private surveys
include topics such as: perceptions of affordability; experiences with and attitudes towards health
insurance; and awareness of new coverage options and financial assistance available under the
Affordable Care Act.
These surveys were fielded during or after the 2015 Open Enrollment Period and together
provide rich information on specific populations that are the focus for the 2016 Open Enrollment
Period. Each survey cited (see Table 3) examined different populations over different periods of
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time with different survey instruments. The definition of being uninsured varies across surveys
and many report findings collectively for those eligible for Medicaid and the Marketplaces. 8
Many uninsured people are eligible for Medicaid or CHIP, or are immigrants who are not
lawfully present (and therefore not eligible for Marketplace, Medicaid, or CHIP coverage), and
their attitudes and experiences may be somewhat different from those whose incomes and
immigration status make them eligible for Marketplace or Medicaid/CHIP coverage.
Table 3. Private Surveys of the Uninsured
Source
Robert Wood Johnson
Foundation National
Survey of Uninsured
Adults
Kaiser Family Foundation
Survey of Low-Income
Americans and the ACA
Commonwealth Fund ACA
Tracking Survey
McKinsey & Company
Consumer Health Insights
Survey
Urban Institute Health
Reform Monitoring Survey

Time Period
May 2015

Sample
Uninsured non-elderly adults

Sample Size9
1,270

Fall 2014
(September
December)
March May
2015
February
2015

19-64 year olds with various


types of coverage

10,502

March 2015

19-64 year olds with various


types of coverage
QHP-eligible uninsured and nonelderly adults with coverage in
the individual market
Uninsured non-elderly adults

4,881
3,007

7,500

Financial Challenges and the Priorities of Uninsured Individuals


People who are uninsured often experience financial barriers to coverage and may place other
priorities over obtaining health insurance.
Only 26 percent of those who are uninsured say that they are doing well financially. Nearly
80 percent have less than $1,000 in savings and about half have less than $100 in savings.10
More than half of people who are uninsured feel financially insecure11 and half had difficulty
affording basic necessities such as food or housing in the past year.12

We have interpreted survey findings in a manner that is consistent with each individual survey, but for simplicity use the term
uninsured broadly in this discussion. We recommend seeing the sources cited in Table 3 for additional details on methodologies,
instruments, timeframes, samples, and definitions. A recent overview by the Urban Institute also provides comparative
information on some of the surveys: Michael Karpman, Sharon K. Long, and Michael Huntress, Nonfederal Surveys Fill a Gap
in Data on ACA, March 2015, available at http://www.urban.org/research/publication/nonfederal-surveys-fill-gap-data-aca.
9
Sample size listed is for the entire survey sample, which may include individuals who have coverage.
10
Robert Wood Johnson Foundation, Understanding the Uninsured Now. June 2015. Available at:
http://www.rwjf.org/en/library/research/2015/06/understanding-the-uninsured-nRow.html.
11
Rachel Garfield and Katherine Young, How Does Gaining Coverage Affect Peoples Lives? Access, Utilization, and
Financial Security among Newly Insured Adults. Kaiser Family Foundation, June 19, 2015. Available at: http://kff.org/healthreform/issue-brief/how-does-gaining-coverage-affect-peoples-lives-access-utilization-and-financial-security-among-newlyinsured-adults/.

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When asked what they would do if they were to become better off financially, many
uninsured people say they would pay down their debt, put money into savings, or make home
or car repairs before buying health insurance.13

Impacts of Being Uninsured on Use of Health Care


Lack of health insurance coverage affects individuals access to and use of health care services.
Most people without health insurance are not confident they can get or afford routine or
major medical care without insurance.14,15
Some uninsured individuals obtain services by paying out of pocket and/or using free or lowcost clinics.16,17 However, one survey indicated that only 28 percent of those who are
uninsured and have ongoing medical care needs feel that they are getting all or most of the
care that they need.18
People who are uninsured are much less likely than their insured counterparts to receive a
check-up or preventive care visit (33 percent versus 74 percent of adults with employersponsored insurance) and more likely to be unable to afford prescription drugs (21 percent
versus 4 percent of adults with employer-sponsored insurance).19
Furthermore, 33 percent of the uninsured have postponed care and never received it, and 34
percent of those who postponed care did so because they could not afford the cost.20
Uninsured individuals experience more problems paying medical and other bills than their
insured counterparts, including having medical bills use up all or most of their savings,
12

Adele Shartzer, Genevieve M. Kenney, Sharon K. Long, and Yvette Odu, A Look at Remaining Uninsured Adults as of
March 2015. Urban Institute, August 18, 2015. Available at: http://hrms.urban.org/briefs/A-Look-at-Remaining-UninsuredAdults-as-of-March-2015.html.
13
Robert Wood Johnson Foundation, Understanding the Uninsured Now. June 2015. Available at:
http://www.rwjf.org/en/library/research/2015/06/understanding-the-uninsured-now.html.
14
Rachel Garfield and Katherine Young, How Does Gaining Coverage Affect Peoples Lives? Access, Utilization, and
Financial Security among Newly Insured Adults. Kaiser Family Foundation, June 19, 2015. Available at: http://kff.org/healthreform/issue-brief/how-does-gaining-coverage-affect-peoples-lives-access-utilization-and-financial-security-among-newlyinsured-adults/.
15
Sara R. Collins, Petra W. Rasmussen, Michelle M. Doty, and Sophie Beutel, Americans Experiences with Marketplace and
Medicaid Coverage. Commonwealth Fund, June 2015. Available at: http://www.commonwealthfund.org/publications/issuebriefs/2015/jun/experiences-marketplace-and-medicaid.
16
Rachel Garfield and Katherine Young, How Does Gaining Coverage Affect Peoples Lives? Access, Utilization, and
Financial Security among Newly Insured Adults. Kaiser Family Foundation, June 19, 2015. Available at: http://kff.org/healthreform/issue-brief/how-does-gaining-coverage-affect-peoples-lives-access-utilization-and-financial-security-among-newlyinsured-adults/.
17
McKinsey & Company. 2015 OEP: Insight into Consumer Behavior. March 2015. Available at:
http://healthcare.mckinsey.com/2015-oep-insight-consumer-behavior.
18
Robert Wood Johnson Foundation, Understanding the Uninsured Now. June 2015. Available at:
http://www.rwjf.org/en/library/research/2015/06/understanding-the-uninsured-now.html.
19
Kaiser Family Foundation. Key Facts about the Uninsured Population. October 5, 2015. Available at:
http://kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population/. Sommers et al. found significant decreases in the
proportion of individuals who said they did not have easy access to medicine after the first Marketplace Open Enrollment Period
and for low-income individuals in states expanding Medicaid, but not for low-income individuals in states that have not yet
expanded. Benjamin D. Sommers, Munira Z. Gunja, Kenneth Finegold, and Thomas Musco, Changes in Self-reported Insurance
Coverage, Access to Care, and Health Under the Affordable Care Act, Journal of the American Medical Association, 2015,
314(4):366-374.
20
Rachel Garfield and Katherine Young, How Does Gaining Coverage Affect Peoples Lives? Access, Utilization, and
Financial Security among Newly Insured Adults. Kaiser Family Foundation, June 19, 2015. Available at: http://kff.org/healthreform/issue-brief/how-does-gaining-coverage-affect-peoples-lives-access-utilization-and-financial-security-among-newlyinsured-adults/.

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having problems paying for basic necessities, or having their bill sent to a collection
agency.21
Concerns about Affordability and Knowledge of Subsidies
According to the Robert Wood Johnson Foundation, nearly 75 percent of uninsured people think
that having health insurance is important. Fewer than 20 percent of those who are uninsured say
they are uninsured because they do not want insurance.22
Nearly 60 percent of those without insurance do not understand or have not heard of APTC.23
People without health insurance are primarily concerned with the affordability of coverage.
A sizeable proportion of those without insurance have not shopped for or obtained coverage
because they did not believe coverage was affordable; however, many of the uninsured also
are not aware of their eligibility for free or low-cost coverage.24,25,26,27,28
In addition, among uninsured adults surveyed by the Kaiser Family Foundation who sought
coverage and said it was too expensive, 42 percent appeared likely eligible for APTC and 14
percent were potentially eligible for Medicaid.29
People without health insurance may also experience gaps in eligibility or confusion about their
eligibility.
About 40 percent of the uninsured who sought coverage in 2014 but did not enroll said that
they were told that they were ineligible for coverage, yet nearly half appeared likely eligible
for APTC (30 percent) or Medicaid (19 percent) at the time that they were surveyed.30
Furthermore, 60 percent of the uninsured have not heard about, or are not sure if they have
heard about, Special Enrollment Periods (SEPs).31

21

Ibid.
Adele Shartzer, Genevieve M. Kenney, Sharon K. Long, and Yvette Odu, A Look at Remaining Uninsured Adults as of
March 2015. Urban Institute, August 18, 2015. Available at: http://hrms.urban.org/briefs/A-Look-at-Remaining-UninsuredAdults-as-of-March-2015.html.
23
Robert Wood Johnson Foundation, Understanding the Uninsured Now. June 2015. Available at:
http://www.rwjf.org/en/library/research/2015/06/understanding-the-uninsured-now.html.
24
Ibid.
25
Rachel Garfield and Katherine Young, How Does Gaining Coverage Affect Peoples Lives? Access, Utilization, and
Financial Security among Newly Insured Adults. Kaiser Family Foundation, June 19, 2015. Available at: http://kff.org/healthreform/issue-brief/how-does-gaining-coverage-affect-peoples-lives-access-utilization-and-financial-security-among-newlyinsured-adults/.
26
Adele Shartzer, Genevieve M. Kenney, Sharon K. Long, and Yvette Odu, A Look at Remaining Uninsured Adults as of
March 2015. Urban Institute, August 18, 2015. Available at: http://hrms.urban.org/briefs/A-Look-at-Remaining-UninsuredAdults-as-of-March-2015.html.
27
Sara R. Collins, Petra W. Rasmussen, Michelle M. Doty, and Sophie Beutel, Americans Experiences with Marketplace and
Medicaid Coverage. Commonwealth Fund, June 2015. Available at: http://www.commonwealthfund.org/publications/issuebriefs/2015/jun/experiences-marketplace-and-medicaid.
28
McKinsey & Company. 2015 OEP: Insight into Consumer Behavior. March 2015. Available at:
http://healthcare.mckinsey.com/2015-oep-insight-consumer-behavior.
29
Rachel Garfield and Katherine Young, Adults who Remained Uninsured at the End of 2014. Kaiser Family Foundation,
January 29, 2015. Available at: http://kff.org/report-section/adults-who-remained-uninsured-at-the-end-of-2014-issue-brief/.
30
Ibid.
31
Robert Wood Johnson Foundation, Understanding the Uninsured Now. June 2015. Available at:
http://www.rwjf.org/en/library/research/2015/06/understanding-the-uninsured-now.html.
22

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Awareness of Penalties for Not Buying Insurance


Uninsured individuals may be more inclined to enroll in coverage for the 2016 coverage year as
a result of the individual shared responsibility payment (tax penalty), which is the larger of 2.5
percent of yearly income or $695 per person ($347.50 per child under 18) in 2016.
Many of the uninsured are not aware of, or know very little about the tax penalty.
Approximately 40 percent of uninsured persons were unaware of the penalty.32
In December 2014, approximately 40 percent of uninsured persons were unsure if they would
pay the penalty for 2014.33
When informed about the penalty, 30 percent of the uninsured who were previously unaware
of the penalty stated that they were more likely to enroll.34

SECTION III: CONCLUSION


Data from the first quarter of 2015 from the NHIS and findings from private surveys provide
insight into the demographic characteristics, financial circumstances, and attitudes towards
health insurance among those who do not have coverage. We estimate that nearly half of the
uninsured population that is QHP-eligible has family incomes between 100% and 250% FPL,
making them likely eligible for APTC and CSR. Almost half of the uninsured who qualify for
Marketplace plans are between the ages of 18 and 34. More than 30 percent are people of color:
19 percent are Hispanic, 14 percent are African- American, and about 2 percent are Asian
American.
Private surveys suggest that the uninsured value insurance but have financial circumstances,
perceptions of affordability, and knowledge gaps that are barriers to enrolling in coverage. Many
people who are uninsured have less than $1,000 in savings and choose other financial priorities
over purchasing health insurance. Even though they do not currently have health insurance,
nearly three-quarters of those without coverage say that they think health insurance is important.
Affordability of coverage is of high concern to those without health insurance, yet many lack
knowledge about subsidies that reduce the cost of purchasing health insurance and their potential
eligibility for this financial assistance. In addition, approximately 40 percent of the uninsured are
not aware of or know very little about the tax penalty.
The next Health Insurance Marketplace Open Enrollment Period, from November 1, 2015 to
January 31, 2016, will offer an opportunity to continue to provide coverage for more individuals
and to reduce the number of uninsured even further.
32

McKinsey & Company. 2015 OEP: Insight into Consumer Behavior. March 2015. Available at:
http://healthcare.mckinsey.com/2015-oep-insight-consumer-behavior.
33
Michael Karpman, Genevieve M. Kenney, Sharon K. Long, and Stephen Zuckerman, Quick Take: As of December, Many
Uninsured Adults Were Not Aware of Tax Penalties for Not Having coverage, the Marketplaces, or the Open Enrollment
Deadline. Urban Institute, February 19, 2015. Available at: http://hrms.urban.org/quicktakes/As-of-December-Man-UninsuredAdults-Were-Not-Aware-of-Tax-Penalties.html.
34
McKinsey & Company. 2015 OEP: Insight into Consumer Behavior. March 2015. Available at:
http://healthcare.mckinsey.com/2015-oep-insight-consumer-behavior.

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METHODS APPENDIX
The national estimates for the nonelderly uninsured, for QHP-eligible nonelderly uninsured, and
for all nonelderly presented in Figures 1-5 and Tables 1-2 are based on ASPE analysis of
National Health Interview Survey Preliminary Quarterly Microdata Files for January-March
2015.35 For the purposes of this analysis, we consider QHP-eligible uninsured to be any
nonelderly, lawfully present individual who is uninsured and has a family income: (a) above
138% of the Federal Poverty Level (FPL) for adults in Medicaid expansion states or at least
100% FPL for adults in states that have not yet expanded, or (b) above 250% FPL for children in
any state. Our QHP eligibility definition is not the same as actual eligibility for coverage or
financial assistance through the Marketplaces, and is an attempt to identify who is most likely to
have or shop for coverage in the Marketplaces. For the purposes of this brief, we have not
included within our definition of QHP eligible individuals whose family incomes are in the
coverage gap (family incomes above Medicaid eligibility and below financial assistance
eligibility through the Marketplaces) in states that have not yet expanded Medicaid, as these
individuals are unlikely to purchase coverage through the Marketplaces. We also do not include
in our definition lawfully present immigrants with family incomes below 100% FPL. The NHIS
Preliminary Quarterly Microdata include the variables used for the selected characteristics shown
in Figures 2-5 and Tables 1-2.
The NHIS quarterly data do not provide information on citizenship or immigration status. Such
information is needed to determine QHP eligibility because immigrants who are not lawfully
present are not eligible for Medicaid (except for emergency services), CHIP, or Marketplace
coverage. The American Community Survey (ACS) Public Use Microdata Sample (PUMS) data
analyzed for this brief include information on place of birth and citizenship but do not
distinguish persons who are not lawfully present from legally resident noncitizens. To exclude
estimated persons who are not lawfully present from our estimates of the uninsured, we
subtracted the estimated number of individuals who are not lawfully present in each category of
interest from the NHIS estimates. Estimates for uninsured individuals who are not lawfully
present are shown in Figure 1 but this population is not included in the estimates for QHPeligible uninsured and their characteristics in Figures 2-5 and Tables 1-2.
Our estimates of immigrants who are not lawfully present are based on ASPE analysis of data
from the 2013 ACS, using an adjustment methodology based on imputations of immigrant legal
status in ASPEs TRIM3 microsimulation model. The TRIM3 imputation methods, originally
developed by Jeffrey Passel and Rebecca Clark in the 1990s, assign noncitizens in data from the
Current Population Survey Annual Social and Economic Supplement (CPS ASEC) to one of four
possible legal statuses: legal permanent resident (LPR, or green card holder); refugee or
asylee; nonimmigrant (temporary legal resident, generally in the U.S. with a student visa or work
visa); or immigrants who are not lawfully present. Our use of the 2013 ACS data assumes that
immigrants who are not lawfully present have not benefited from the coverage gains under the

35

Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey Early
Release Program. Preliminary Quarterly Microdata Files: National Health Interview Survey, JanuaryMarch 2015. August
2015. Available at: http://www.cdc.gov/nchs/data/nhis/earlyrelease/microdata.pdf.

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Affordable Care Act since 2013 because they are not eligible for the Marketplace or Medicaid
expansion.
Another important limitation of the NHIS estimates is that they measure family income rather
than income for the Health Insurance Unit (HIU), which comes closer to the tax concepts used to
determine eligibility for Medicaid, CHIP, and the Marketplaces. Family income and HIU income
will be the same for many families, but for others the two concepts will produce different results.
The income of a young adult living at home, for example, would be counted in family income
along with that of parents who might earn more, but the childs and parents income would be
broken out separately in HIU income. Research by the State Health Access Data Assistance
Center (SHADAC) suggests that on net, using HIU rather than family income categorizes more
individuals below Medicaid income eligibility limits and fewer individuals within the QHPeligible income range.36 Data to construct HIU income was not available in NHIS.
ASPE appreciates the assistance of the Centers for Disease Control and Prevention National
Center for Health Statistics Research Data Center in facilitating our access to and analysis of the
restricted NHIS Preliminary Quarterly Microdata Files. The findings and conclusions in this
brief are those of the authors and do not necessarily represent the views of the Research Data
Center, the National Center for Health Statistics, or the Centers for Disease Control and
Prevention.

36

State Health Access Data Assistance Center (SHADAC). Defining Family for Studies of Health Insurance Coverage.
March 2012. Available at: http://www.shadac.org/files/shadac/publications/SHADAC_Brief27.pdf.

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